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Homicidal suicidal patients were rare and disturbing on psych, carefully locked up behind doors, but when they’re loose on the medical floor, and security refuses to help, they are downright scary.

So this morning I went to check on our dear friend. He was waiting in the hallway by our office, and could barely let me finish talking to another patient. We got back to his room, and he told me that he was very anxious. Abdominal pain? “A non-issue, non-concerning, completely not serious.” But very anxious, and upset about his life being wasted and hopeless and a failure. At this point I had not yet realized how manic he had become, so I suggested that with prayer and God’s help his life could still be turned around. He got agitated again and said that would be as useful as praying to the water tower outside. So I decided to just stick to the medical side, checked his belly (much better), and promised him ativan and any other necessary benzos (mental qualification, only one needed at a time) as soon as I could get ahold of the doctors. By the time I got out of his room, I was convinced he was definitely suicidal, possibly homicidal, and certainly unhinged.

He then followed me around all morning, complaining of anixety and abdominal pain alternately. On rounds, the attending asked why he came to the hospital, and he said, “I quit smoking four weeks ago. I think that’s quite an accomplishment. Now, I did backtrack, and smoke the last two days, but I don’t consider that a failure. It’s – it’s – it’s something to take under consideration, definitely, it’s a situation, but it’s not a problem.” So we all got out of the room.

Later on the resident went to check on him before consulting psychiatry, and he tried to hit her. So she paged psych and security both. Psych didn’t answer for half an hour, which felt like forever with him standing in our doorway yelling that he wasn’t angry, and the resident had an attitude problem, then marching off, apparently to leave the hospital, then coming back to argue some more. Security arrived, very comfortable-looking in slick black uniforms, gold badges, leather belts, and informed us that they’re very sorry, but they can’t restrain a patient without a pink slip (involuntary admission for psychiatric reasons form). And lo and behold, in this unique hospital, internists can’t sign pink slips; only psychiatrists can sign pink slips. And of course psych wasn’t talking to us.

So he continued to behave very threateningly, while we paged psych without avail. Finally I went upstairs to the psych unit, found it deserted except for a couple patients and one nurse. When she heard the words “homicidal, suicidal, manic,” she became very helpful, and paged her doctors till she tracked them down in a staff meeting. They then called the resident and cheerfully told her not to bother them if the patient wasn’t on the floor. They certainly weren’t going to go talk to him while he was out smoking.

The patient is now sitting in front of the nurses’ station, taking off his clothes and folding them. We paged

I was dreaming about a patient who needed emergency surgery or they were absolutely going to die, and there I was rushing around this nightmare hospital trying to find my resident and a surgeon and an anesthesiologist, and I couldn’t find anybody – and woke up to look at the alarm clock, and I was supposed to be at the hospital already.

So I ran out the door mumbling about the patient who was dying, and had been driving for five minutes before I calmed down and decided no one was going to die for lack of my presence, at least not yet. Actually everyone comes in late on Sundays, so I was only half an hour later than the resident, and since we didn’t have many patients she didn’t particularly mind. So I spent the last couple of hours trying to figure out the patients we’re covering for the other team. The half of our team which isn’t on call doesn’t come in on the weekend, so we have to see their patients, and write notes and orders for them. The idea is that they should have left clear instructions and notes so we can carry on their plans. They must have been tired yesterday, because it took us a long time to figure out their patients, and then we reversed half their orders. As in, one guy who appears to have a white count and a chest infiltrate, whom they didn’t put on antibiotics, and another guy with ileus (bad constipation) which resolved overnight, whom they did put on one of the big-gun antibiotics, I don’t know why. So we switched that around.

So now I have time for some psychoanalysis. Way back when I was a first year, I spent two weeks with an OB/GYN in private practice. He let me scrub in on his surgeries, though not touch anything, and that was enough to delight me back then. One day he and his partner were being paged frantically out of their scheduled gyn surgeries for a lady upstairs in labor and delivery. I went up with the younger partner to see. He found the lady, about 29 weeks pregnant, saying she hadn’t felt fetal movement since yesterday. She had come in then, been told the heart sounds were ok, and sent home. Still nothing moving, so she came back. When she was seen in the ER, there were fetal heart tones, but erratic, so she was sent upstairs. There, she was put in a room, and on a fetal monitor, and then the heart tones were lost, which was when the stat paging started. He listened and looked, and sure enough, no movements, no sounds. He started paging anesthesiology, but it took almost half an hour to get the staff there, start the epidural, and finally start the Csection. They pulled the baby out, and she was blue and white, not moving or crying. The nurses whisked her off to the NICU, but could do nothing. The doctor had to sew up the incisions, and nobody could say anything. Everybody but the mother had seen the baby, had heard it not crying, knew that if no one came in to say anything, that was it; and no one wanted to say it out loud while the mother still had to hold still for the surgery. After sewing up we went across to the NICU to look at the baby. She was white – dead white – cleaned and wrapped up. She was so beautiful; a little small, but not much, and absolutely perfect. No organs visibly missing, no holes – no reason to be dead. I felt like if someone would just hug her instead of laying her on the table and looking at her, maybe she would start crying. But no one could hold her, and she didn’t move. 

So I’ve promised myself to learn how to start epidurals, so I never have to wait for anesthesiology if there’s a real emergency. There was a reason, of course – the OR was full that day, and some emergency surgeries had been started downstairs, which had used up the free CRNAs and residents; and maybe the baby wouldn’t have made it even if the Csection had started the minute the doctor saw the heart tones were gone. But I will not be dependent on anesthesia. I don’t want to see another little white baby like that.

Proverbs 22:20-21  “. . . [I have] written to thee excellent things in counsels and knowledge, that I might make thee know the certainty of the words of truth; that thou mightest answer the words of truth unto them that send unto thee.” How wonderful to have a source of certain knowledge in this age of irrational epistemology, where no one can know anything for sure, and one man’s guess is as good as another’s! God’s excellent word is the unshakeable source of truth, and “whosoever believeth on him shall not be ashamed.”

On another line, I was also reading the Chicago Times’ archive of Mark Steyn’s articles. He’s a Canadian who writes the cleverest analysis of US and European politics. Here’s his Christmas take on declining birth rates in Europe. “[D]emographics is a game of last man standing. It’s no consolation that Muslim birth rates will be as bad as yours in 2050 if yours are off the cliff right now. The last people around in any numbers will determine the kind of society we live in.”

As has been said repeatedly, postmodern humanism is a culture in love with death, and they will assuredly reap what they sow: their own deaths, and the death of whatever culture they’ve managed to grow in the fertile soil of our Christian heritage. And certainly Islam is set to take over when Europe dies. But what none of the gloomy birth-rate prognosticators is noticing is the [geometrically] growing population of Christians in America who believe the Bible enough to seek dominion on earth – and to “be fruitful and multiply.” I don’t think the Muslims will find a vacuum; they’ll find another group of people who also love children. And in the end, Islam will fall too, because just as much as the humanists, they are in love with death (just by suicide, not abortion and sterility). Jesus Christ in the person of Wisdom says, “Whoever hates me loves death,” because “the wages of sin is death, but the gift of God is eternal life.”

This is good news, but it is not yet reason to rejoice. We are not living in a private enclave; we cannot rejoice because so many human beings are running headlong towards destruction. Our response should not be glee at their inevitable failure, but compassion for their loss, and a vigorous attempt to turn them towards the truth.

It turns out that the man with the huge pleural effusion and swollen abdomen does not have cancer, just heart failure and cirrhosis. After some hefty doses of lasix and a successful thoracocentesis, he is feeling and looking much better, except for his belly, which is still huge. Now, some doctors might send him home. But not us. The fearless teaching doctors and students on the teaching service see a chance for a procedure: paracentesis!

It tells you something about the incidence of cirrhosis in our patient population that both the intern and the resident are “signed off” on paracentesis. So, that means I can do it! My cup runneth over. Week after next I’ll be on a semi-surgical service (OB), and here we are, after I’d given up hope of getting to do anything interesting on internal medicine.

I might have known it. After all that excitement, ultrasound showed not enough fluid to be worth tapping.

Before we went down to see, the resident wanted me to recite all the steps in the procedure, which I mostly knew, except for saying that I would put the big catheter-needle “straight in,” which I meant as opposed to slanted, but she strongly objected to the suggestion of putting it in fast. Some other residents had stopped by, and they all started quizzing me about complications (peritonitis, ruptured intestine, death, etc), and swapping their horror stories of procedures gone wrong, till I was completely scared, too scared to even say I didn’t want to do it anymore. How am I ever going to do surgery?

So I’m not too disappointed. But one of the other interns has developed a strong desire to do procedures, and we have another patient whom we have better reason to believe has ascites. I’m not asking to do anything with him, as he is already very angry with the hospital in general, and already complaining of severe pain from the swelling; so he’s guaranteed to be a very difficult stick, and I would hate to be involved if any complications did happen. So this afternoon should be interesting.

You know a society is in trouble when ancient Greek ethics start to look good compared to modern ones. Ancient Greece was, after all, a land that idolized warriors, whose favorite piece of literature spends thousands of lines describing the deaths of warriors (“he fell to the ground and his armor clattered around him”), which allowed infanticide, where homosexuality was an accepted institution, whose pantheon consisted of all-too-human lustful, violent, treacherous gods – and yet they had better medical ethics than modern America. Hippocrates was an unenlightened pagan, who swore by the imaginary Aesculapius and Apollo, and yet I’d rather take him for a mentor than many Oregon doctors: “I swear . . . I will neither give a deadly drug to anyone who asks for it, nor will I make a suggestion to this effect.”   

Yesterday the Supreme Court, in a 6-3 decision (Roberts, hurrah! and Scalia and Thomas dissenting) refused to allow the US Attorney General the authority to prosecute Oregon doctors who assist in suicides under an Oregon law. (Opinion here, for anyone who wants to slug through the twisted reasoning.) So apparently the AG can prosecute California cancer patients for using marijuana, per that state’s statutes, but cannot prosecute Oregon doctors for, essentially, murder, when it is justified by that state’s laws. Does nobody else see a problem here?! The decision is being hailed by “death with dignity” advocates who hope to extend this type of law into other states. Vermont, to nobody’s surprise, is high on the list.

The resident has cleverly disposed of all of our patients before we start call, and rounds aren’t for a while yet, so we can examine the multitudinous fallacies behind the Oregon law. Essentially, doctors can prescribe fatal doses of barbiturates to patients who are determined to have a “terminal” condition (expected to die within 6 months), and who are judged to be competent to make decisions, and who make two written requests fifteen days aparts.

For being a third-year student, I have been pimped remarkably little, compared to some of my classmates. I don’t count it when it’s just me and the attending or resident; that’s plain teaching, to ask questions, see how much I know, then explain what I don’t. I only mind it the slightest bit when it’s on rounds, and everyone else is listening with interest to see how well or how badly you’ll do.

Attendings, the senior doctors who supervise the residents – usually switch off every two weeks, because they’re on call continually. Not that residents like to call the attending in the middle of the night, but it can happen, with no weekends off. So our new attending is the chief of hematology/oncology at the VA; nice older gentleman, stoop-shouldered from peering into microscopes, with a harmless manner, but very sharp mind. He seems to run rounds very fast, which is fine by us. Today, being an on-call day, we didn’t have any new patients to discuss in detail, so he took us around to his office, which is a tiny lab room stuffed with refrigerators, hoods, microscopes, and jugs of reagent, and stained papers on top of everything.

He invited me and the other medical student to pick one to be quizzed today, so I took it, on the principle of getting things over with quickly. We sat down on opposite sides of a demonstration microscope – two sets of eyepieces, so he can find things and show them to me at the same time. “Healthy elderly gentleman, pre-op CBC before a hernia repair, found to have a white cell count of 50,000 [normal is less than 10,000]. Looking at his peripheral [blood] smear. . .” I think he forgot that this exact same case had been part of the heme/onc quiz yesterday. The patient of course has CLL, chronic lymphocytic leukemia, an indolent, slowly progressive, incurable leukemia most common in the elderly. And I had been expecting some detailed questions for the quiz yesterday, so I had studied it all: prognosis (10+yr life expectancy), cure rate (none), complications (blast crisis, where the CLL suddenly turns into AML, acute myelocytic leukemia, and the patient dies in weeks), and molecular diagnosis (look for CD5 and CD23 markers, which will distinguish CLL from mantle cell lymphoma, which has CD5 but not CD23).

The attending of course was delighted with me. We had our own private conversation, as everyone else had forgotten about the markers. So all morning the residents have been teasing me about showing off in heme/onc, which isn’t even a field that I’m interested in. I haven’t yet managed to persuade them that if he had asked about anything else at all (AML, ALL, CML) I would have been completely lost.

We had very few patients until this morning, except now along with the snow outside we’re getting snowed with patients too. My resident, in spite of her grumpy manner, actually is very kind about picking up overworked residents’ patients, with the result that she gets herself overworked eventually. Right now we’re clearing house for the other teams, and the ICU too, by letting them dump all over us. So hopefully we’ll pick up a few interesting patients somewhere in there.

The other day I was checking on one of my patients, who had told me on admission that he was an ordained minister in one of Pentecostal-type churches. I suppose it says I pay too much attention to appearances; I had a hard time giving much credence to an overweight, stubbly man in yellow pajamas and a nasal cannula. Then that morning he asked suddenly if I was Coptic. I was dumbfounded. How did he know about the Copts? He had met a priest in a doctor’s office once. Then he began telling me about how wonderful Clement of Alexandria was, and Nicholas of Myra, and although he didn’t recognize Athanasius’ name, he did know about the Council of Nicea, and the Creed, and the importance of defeating Arius’ heresy. He started calling me “sis,” for “sister,” which is a little familiar for my taste, but who cares. Anyone who knows about Clement and Nicholas can call me “sis” any day.

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